围术期糖尿病与心血管病相关性研究及处理进展

糖尿病是心血管病重要的独立高危因素。糖尿病增加心肌缺血损伤的危险性，引起心肌本身和心肌内小血管病变，抑制心肌缺血预处理的作用。现就糖尿病对心血管病的影响及糖尿病病人围术期的处理进展作一综述。     

Understanding cardiac biomarkers in end-stage kidney disease: Frequently asked questions and the promise of clinical application

A novel strategy in the management of cardiovascular disease in patients with end-stage kidney disease is the use of biochemical markers to facilitate the detection of cardiovascular abnormalities in the hope that this will allow effective therapy to be instituted earlier. The cardiac troponins and B-type natriuretic peptide are among the best studied of these biochemical markers of cardiovascular disease. However, controversy remains regarding the interpretation of such results and the subsequent clinical application of these biomarkers, particularly when abnormal in patients with end-stage kidney disease. This review addresses some of the important issues to consider with the interpretation of abnormal cardiac troponin and B-type natriuretic peptide results in patients undergoing dialysis.     

Associations between vascular calcification, arterial stiffness and bone mineral density in chronic kidney disease.

BACKGROUND: Vascular calcification (VC) and arterial stiffness are major contributors to cardiovascular (CV) disease in chronic kidney disease (CKD). Both are independent predictors of CV mortality and are inversely correlated with bone mineral density (BMD). Few studies have addressed the extent of VC in the pre-dialysis CKD population, with associated measurements of BMD and arterial compliance. METHODS: We report cross-sectional data on 48 patients with CKD (GFR 17-55 ml/min) assessing the prevalence of VC and its associations. All patients had computed tomography (CT) scans through abdominal aorta and superficial femoral arteries (SFAs) to determine VC, pulse wave velocity (PWV) using SphygmoCor device (AtCor PWV Inc., Westmead, Australia) measuring arterial stiffness, and dual-energy X-ray absorptiometry (DEXA) scans to determine BMD, as well as serum markers of renal function and mineral metabolism. RESULTS: Patients, 71% male, 54% diabetic, had a median age 64.5 years. Mean estimated GFR was 35.1 +/- 10 ml/min. Mean PWV was 10.0 +/- 4.5 m/s and mean aortic VC score was 421.5 +/- 244 Hounsfield units, with 90% of subjects having some aortic VC present. In univariate linear regression analysis, aortic VC correlated positively with age (r 0.50, P < 0.001), triglycerides (r 0.47, P = 0.002) and PWV (r 0.33, P = 0.03). There was also greater VC with declining renal function (r -0.28, P = 0.05). There was no significant association between VC and serum markers of mineral metabolism, however phosphate and Ca x P correlated positively with PWV (r 0.35, P = 0.02, r 0.36, P = 0.02, respectively). There was also a positive association between PWV and triglycerides (P = 0.008), and a trend towards greater PWV with increasing age (P = 0.09). In multivariate regression analysis only increasing age and triglyceride levels were significantly associated with aortic VC and PWV. Mean spine and femoral T-scores on DEXA were 0.48 and -1.31 respectively, with 13% of subjects having femoral T-score <-2.5 (osteoporotic range). SFA VC inversely correlated with femoral T-scores (r -0.43, P = 0.004); however, there was a positive (likely false) association between spine T-scores and aortic VC (r 0.37, P = 0.01), related to the limitation of vertebral DEXA in CKD. CONCLUSION: There is a high prevalence of VC in pre-dialysis CKD patients, worse with increasing age, triglycerides and reducing renal function. Correlation exists between VC and PWV and determination of one or both may be useful for CKD patient CV risk assessment. Femoral BMD is inversely associated with SFA VC, but measurement of vertebral BMD by DEXA is unreliable in CKD patients with aortic VC.     

Reproducibility of pulse-wave analysis and pulse-wave velocity determination in chronic kidney disease.

BACKGROUND: Indices of central arterial stiffness, derived by use of applanation tonometry, have shown to be strong independent predictors of cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD). The objective of this study was to evaluate the intra- and inter-observer and day-to-day reproducibility of pulse-wave analysis (PWA) and pulse-wave velocity (PWV) in pre-dialysis patients with CKD stages 3-5 using applanation tonometry with the SphygmoCor software and hardware. METHODS: Double recordings of the radial pressure waveform and the aortic and brachial PWV were performed under standardized conditions in 19 CKD patients with a mean GFR 25.3 ml/min/1.73 m(2) (range 9.9-42.2) by two trained observers and repeated by one of the observers within a week. RESULTS: The mean inter-observer and day-to-day differences (+/-2 SD) for the augmentation index (AIx) were 0.9 +/- 15.8% and 2.6 +/- 11.2%, for subendocardial viability ratio (SEVR) -0.9 +/- 15.5% and -0.4 +/- 24.7%, for aortic pulse pressure (PP) 1.4 +/- 13.3 mmHg and 0.3 +/- 20.9 mmHg and for aortic PWV 0.3 +/- 3.2 m/s and -0.7 +/- 1.9 m/s, respectively. Intra-observer differences were calculated for each of three sets of double measurements and showed good reproducibility as well. Calculations on sample size needed in a clinical trial showed a limited number of patients needed in a clinical study over time. CONCLUSIONS: PWA and PWV based on applanation tonometry using the SphygmoCor software and hardware are highly reproducible in pre-dialysis patients with CKD with the day-to-day variation being in accordance with the intra- and inter-observer variation. Thus, applanation tonometry using the SphygmoCor system is a simple, non-invasive method to assess central haemodynamics in clinical trials in patients with pre-dialysis CKD with only a limited number of patients needed to detect significant differences.     

�ϲ���Ѫ�ܼ�����ǻ���������ռ�����

腹腔镜在普外科应用范围及适应证日益扩大,许多复杂的手术如腹腔镜下胃癌根治术、结直肠癌根治手术、肝切除,甚至腹腔镜胰十二指肠切除术都已经开展,同时合并心血管疾病需要行腹腔镜手术的病人也越来越多。虽然相对于开腹手术,腹腔镜手术因为其对生理打击较小因而其心血管风险也相对小,被列为对心脏低风险的非心脏手术[1]。但腹腔镜所需的CO2气腹和病人体位导致复杂的病理生理改变,对于这些病人具有许多不利的影响,因而对这一类病人的腹腔镜手术围手术期处理,麻醉医生和外科医生也需要格外注意,包括掌握腹腔镜手术环境对病人的影响和相应的…     

Association between 25-hydroxyvitamin D deficiency and cardiovascular disease in type 2 diabetic patients with mild kidney dysfunction.

BACKGROUND: A potentially modifiable and underestimated risk factor for cardiovascular disease (CVD) in subjects with kidney dysfunction is 25-hydroxyvitamin D deficiency, although the relationship between inadequate vitamin D status and manifest CVD in type 2 diabetic subjects with mild kidney impairment has not been extensively examined. METHODS: We evaluated the relationship between serum 25-hydroxyvitamin D concentrations, baseline kidney function (estimated using the modification of diet in renal disease equation) and manifest CVD (myocardial infarction, angina, ischaemic stroke, coronary revascularization or carotid endarterectomy) among 462 consecutive patients with type 2 diabetes. RESULTS: In the whole population, the mean age was 62+/-7 years, 64% were men, 76.3% had hypertension and the mean estimated glomerular filtration rate (GFR) was 94+/-33 ml/min/1.73 m(2). Kidney function was strongly and inversely associated with CVD. In multivariate logistic regression analysis, there was an inverse association between serum 25-hydroxyvitamin D concentrations and prevalent CVD [odds ratio 0.95 (95% CI 0.92-0.98; P=0.001)] in the whole population independent of baseline kidney function and other known risk factors. Additionally, the association between serum 25-hydroxyvitamin concentrations and CVD [odds ratio 0.97 (95% CI 0.94-0.99; P=0.045)] remained statistically significant in participants in the lowest estimated GFR tertile after adjustment for potential confounders. CONCLUSIONS: Decreased 25-hydroxyvitamin D concentrations are independently associated with prevalent CVD in type 2 diabetic patients with mild kidney dysfunction.     

Fast-track cardiac anaesthesia in the elderly: effect of two different anaesthetic techniques on mental recovery

Elderly patients may be considered for ‘fast-track’cardiac anaesthesia, but can suffer psychological complicationsand slow recovery of mental function after surgery, which caninterfere with recovery. Reduced metabolism and changed distributionof anaesthetic and sedative agents can cause poor recovery.We made a prospective randomized comparison of mental function,haemodynamic stability and extubation and discharge times inelderly patients (65–79 yr) receiving two premedication,anaesthetic and sedative techniques. Patients received eitherpropofol (n=39) (fentanyl 10–15 µg kg^–1and propofol 2–6 mg kg^–1 intraoperativelyand a propofol infusion for 3 h postoperatively) or premedicationwith lorazepam followed by midazolam for anaesthesia (n=39)(fentanyl 10–15 µg kg^–1 and midazolam0.05–0.075 mg kg^–1 intraoperatively anda midazolam infusion for 3 h postoperatively). Impairmentof mental function was noted in 41% of patients in the propofolgroup and 83% in the lorazepam and midazolam group (P=0.001)18 h after extubation. Patients in the propofol group wereextubated earlier [1.4 (SD 0.6) vs 1.9 (0.8) h, P=0.02];and reached standard intensive care unit discharge criteria[7.6 (4.6) vs 14.2 (13) h, P=0.02] and hospital dischargecriteria [4.3 (1.0) vs 4.9 (1.1) days, P=0.04) sooner than patientsin the lorazepam and midazolam group, but actual discharge timesdid not differ between the groups. Haemodynamic values werestable in both groups.Br J Anesth 2001; 86: 68–76     

Elevated levels of plasma von Willebrand factor and the risk of macro- and microvascular disease in type 2 diabetic patients with microalbuminuria.

BACKGROUND: The purpose of this study was to examine the concept suggesting that microalbuminuria in combination with high levels of plasma von Willebrand factor is a stronger predictor for cardiovascular disease and microvascular complications than microalbuminuria alone in type 2 diabetic patients. METHODS: One hundred and sixty patients with type 2 diabetes mellitus and persistent microalbuminuria were followed for an average of 3.8 (SD 0.3) years. 70% of the patients were treated with angiotensin converting enzyme (ACE)-inhibitors. Patients in this subanalysis were divided into two groups according to baseline plasma von Willebrand factor levels below or above the median. The main outcome was cardiovascular disease (cardiovascular mortality, non-fatal stroke, non-fatal myocardial infarction, coronary artery bypass graft and revascularization or amputation of legs), progression to diabetic nephropathy or progression in diabetic retinopathy. RESULTS: At baseline the two groups were comparable for HbA(1c), fasting levels of s-total-cholesterol, s-HDL-cholesterol and s-triglycerides, systolic and diastolic blood pressure, gender, known diabetes duration, smoking habits, previous cardiovascular disease and antihypertensive therapy as well as retinopathy. Odds ratio for cardiovascular disease was 1.11 (95% CI 0.45-2.73, P=0.82) (multiple logistic regression), odds ratio for progression to nephropathy was 1.08 (0.41-2.85, P=0.87) and odds ratio for progression in retinopathy was 0.96 (0.46-2.00, P=0.92), all with plasma von Willebrand factor levels above the median. CONCLUSIONS: Our results do not support the suggestion that the combination of high plasma levels of von Willebrand factor and microalbuminuria is a stronger predictor for cardiovascular disease, progression to diabetic nephropathy or progression in diabetic retinopathy than microalbuminuria alone in patients with type 2 diabetes and persistent microalbuminuria.     

Semi-invasive monitoring of cardiac output by a new device using arterial pressure waveform analysis: a comparison with intermittent pulmonary artery thermodilution in patients undergoing cardiac surgery

BACKGROUND: Thermodilution technique using a pulmonary artery catheter (PAC)is a widely used method to determine cardiac output (CO). Itis increasingly criticized because of its invasiveness and itsunclear risk–benefit ratio. Thus, less invasive techniquesfor measuring CO are highly desirable. We compared a new, semi-invasivedevice (FloTrac/Vigileo^TM) using arterial pressure waveformanalysis for CO measurement in patients undergoing cardiac surgerywith bolus thermodilution measurements. METHODS: Forty patients undergoing coronary artery bypass grafting orvalve repair were enrolled. A PAC was inserted and routine radialarterial access was used for semi-invasive determination ofCO with the Vigileo. CO was measured simultaneously by bolusthermodilution and the Vigileo technique after induction ofanaesthesia (T1), before cardiopulmonary bypass (CPB) (T2),after CPB (T3), after sternal closure (T4), on arrival in theintensive care unit (ICU) (T5), and 4 h (T6), 8 h(T7), and 24 h after surgery (T8). CO was indexed to thebody surface area (cardiac index, CI). RESULTS: A total of 244 pairs of CI measurements were analysed. Biasand precision (1.96 SD of the bias) were 0.46 litre min^–1m^–2 and ± 1.15 litre min^–1 m^–2 (r =0.53) resulting in an overall percentage error of 46%. Subgroupanalysis revealed a percentage error of 51% for data pairs obtainedintraoperatively (T1–T4), 42% in ICU (T5–T8), and56% for values obtained during low CI (T1–T8). CONCLUSIONS: In cardiac surgery patients, CO measured by a new semi-invasivearterial pressure waveform analysis device showed only moderateagreement with intermittent pulmonary artery thermodilutionmeasurement.     

Death within the first year after kidney transplantation – an observational cohort study

The risk of death within the first year postkidney transplantation is not well described in the contemporary era. We extracted data on all kidney transplant procedures performed in England between April 2001 and March 2012. Data linkage analysis was performed between Hospital Episode Statistics and the Office for National Statistics to identify all deaths. Cox proportional hazard models were performed to identify factors associated with 1‐year mortality. 566 deaths (3.0%) occurred within the first year post‐transplant (from 19 103 kidney transplant procedures analysed). Infection, cardiovascular events and malignancy were classified in 21.6%, 18.3% and 7.4% of death certificates, respectively. Among recipients with prior myocardial infarct history who died within the first year, 38.8% of deaths were attributed to a cardiac‐related event. Malignancy‐related death was responsible for 61.5% of 1‐year mortality for allograft recipients with pretransplant cancer history. 22.1% of deaths included kidney failure as a contributory factor on the death certificate (3.3% specifically stated allograft failure). Variables associated with 1‐year mortality included deceased‐donor kidney, increasing age, residence in socioeconomically deprived area and history of select medical comorbidities pre‐operatively. We conclude 1‐year mortality postkidney transplantation is low, but in select allograft recipients, the risk of death increases considerably.